Public health has taken another blow. They say these things come in threes. We have leading conservative presidential candidates telling people that vaccines cause autism. A conservative senator in Tennessee just told his constituents that it is "virtually impossible" to spread HIV through heterosexual contact. And now, we are politicizing the screening and treatment of breast cancer. I can't stop thinking about the cultural damage here. Has anyone else considered what we just lost as a nation? We disagree on just about everything these days. The notion that breast cancer is a disease worth fighting is one of the few remaining things everybody could agree on. That has now been destroyed; and for what? At the end of the day, this was over $700,000 dollars. To destroy such a cherished and unitary cultural icon for such a petty trifle, for such a cheap political victory. It must take an exceptionally vindictive person to want to make that trade.
At any rate, this was an unforced error of staggering proportions on the part of the Komen Foundation itself. Before this story broke, I suspect that very few people knew that Komen gave money to Planned Parenthood. Even if people knew Komen was providing breast cancer care at Planned Parenthood clinics, what kind of person would possibly care? One would think self-interest alone would have led Komen to stay out of this debate. Now that they have taken sides, its probably too late. If they stand firm and abandon low-income women, they will alienate at least the 75% of Americans who support abortion rights in some form or another. Arguably they will lose more than that, since obviously not everyone who is anti-choice thinks depriving poor women of breast cancer screening is worth a political point. Alternatively, Komen could do the right thing and reverse course. In doing so they would become a perpetual target for religious bullies who are always looking for another battle to fight. Either way, what used to be a non-controversial, unitary force, the fight against breast cancer, will be reduced into another yearly battle in our incessant culture wars.
I do think there is a way out. Komen needs to stand with low-income women and support breast cancer services, and provide concrete data that show that donors' money is being used only for breast services. Conservative women should stand with them when they do - because they should recognize that this isn't worth it, and that there are better and less destructive venues in which to have the abortion fight. People should remember why they supported the Komen Foundation in the first place and leave politics aside for once.
Showing posts with label Religion and Philosophy. Show all posts
Showing posts with label Religion and Philosophy. Show all posts
Friday, February 03, 2012
Wednesday, September 21, 2011
Americans, death, and the health care system
This short commentary touches on one of the major problems that we have in the health care system: unrealistic expectations. Really, having great expectations is something that is almost quintessentially American. We generally aren't good at waiting for things or taking "no" for an answer. Health care is no different.
I sometimes get the impression that patients think we (physicians) can do just about anything for them, reverse any condition, and make them feel like brand new. In clinic, if you tell a patient that their condition may not improve, or that there isn't much we can do to help them, they almost always look at you like you're crazy. People tend to have very unrealistic expectations as to what we are capable of.
This especially becomes obvious at the end of life. As patients get closer and closer to death, some people still refuse to believe that we can't completely reverse everything. Even if you tell them as much, its almost as if they don't understand what they are being told. Their baseline perception of the world can be very mixed-up too. To some people, withdrawing care, IE letting the natural course of things proceed, is tantamount to killing the patient. Ceaseless medical intervention for some people is the natural course of things.
Its really very bizarre to me sometimes. Especially compared to other industrialized nations, America is a very religious place. Many if not most Americans profess strong belief in God. And yet, the inability of many people to accept death as a natural course of things, as a legitimate outcome, is just something I still never ceased to be amazed by. South Park made fun of the Terry Schiavo case years ago, but they also were on point in their underlying message. In that case, the Republicans were screaming that we were playing God by removing the feeding tube. Well, no - actually, we were playing God when we put the feeding tube in.
End of life care is enormously expensive. Arranging panels to help patients decide what their end-of-life objectives were was one of Obamacare's greatest pushes. It had the potential to save money AND to improve patient's quality of life (I don't consider prolongued and pointless hospital stays to be improvements in quality of life). Unfortunately, the idea was demagogued to death by members of the opposition political party. Very frustrating, but its something we need to start thinking about as a nation.
I sometimes get the impression that patients think we (physicians) can do just about anything for them, reverse any condition, and make them feel like brand new. In clinic, if you tell a patient that their condition may not improve, or that there isn't much we can do to help them, they almost always look at you like you're crazy. People tend to have very unrealistic expectations as to what we are capable of.
This especially becomes obvious at the end of life. As patients get closer and closer to death, some people still refuse to believe that we can't completely reverse everything. Even if you tell them as much, its almost as if they don't understand what they are being told. Their baseline perception of the world can be very mixed-up too. To some people, withdrawing care, IE letting the natural course of things proceed, is tantamount to killing the patient. Ceaseless medical intervention for some people is the natural course of things.
Its really very bizarre to me sometimes. Especially compared to other industrialized nations, America is a very religious place. Many if not most Americans profess strong belief in God. And yet, the inability of many people to accept death as a natural course of things, as a legitimate outcome, is just something I still never ceased to be amazed by. South Park made fun of the Terry Schiavo case years ago, but they also were on point in their underlying message. In that case, the Republicans were screaming that we were playing God by removing the feeding tube. Well, no - actually, we were playing God when we put the feeding tube in.
End of life care is enormously expensive. Arranging panels to help patients decide what their end-of-life objectives were was one of Obamacare's greatest pushes. It had the potential to save money AND to improve patient's quality of life (I don't consider prolongued and pointless hospital stays to be improvements in quality of life). Unfortunately, the idea was demagogued to death by members of the opposition political party. Very frustrating, but its something we need to start thinking about as a nation.
Thursday, June 30, 2011
Why I love oncology
This applies to medicine as a whole, but in particular to oncology. A lot of people "question my sanity" when I tell them that I want to be in a field like oncology. "Wouldn't it be depressing to be treating cancer patients all of the time, especially when ones that you become close with ultimately have unsuccessful treatments?"
It is all about how one looks at things. For starters, maybe cancer as a disease is a depressing thing but oncology as a specialty is amazing. Before 1950 or so, all cancers had the same prognosis: zero, give or take a few hundredths of a percent. Now, we save people all of the time. Colon cancer can be resected and cured with surgery and chemo. Testicular cancer has a 95% survival rate when only a few decades ago it was 5%. Many pediatric leukemias we can treat with some efficacy. For cancers we can't cure, we can certainly make the remaining life better. In oncology, is it isn't about who you lose - its about who you don't. Those are the cases where, after, you can look Mother Nature in the eyes and say "we beat you."
The other thing about oncology, although this applies to other fields as well (for example, transplant surgery, which I am on right now), is the effect it has on me as a person. Its so easy to go home at night and be tired and think, "I want to do nothing", or "I am too tired to go on a run." Then you remember the stage IV cancer patient who is bed-ridden and beyond cure, without long to live. Or you might remember the young guy who is stuck in the ICU. He already had a liver transplant once to save his life, but his immune system has systematically destroyed it despite our best efforts. Each day we see the new numbers, each day more abnormal, as the liver functions less and less.
Remember those things and all of the sudden, you have the energy to go for a run or to go out and socialize - because you can. Because you are so aware that someday, you won't be able to. Think forward - many of us will be in that very position some day. What would we give for the chance to come back and be 28 and be healthy enough to do those things? If that time comes for me, I will smile when it does, because I will know I did. With the right perspective, oncology is an incredibly uplifting discipline.
It is all about how one looks at things. For starters, maybe cancer as a disease is a depressing thing but oncology as a specialty is amazing. Before 1950 or so, all cancers had the same prognosis: zero, give or take a few hundredths of a percent. Now, we save people all of the time. Colon cancer can be resected and cured with surgery and chemo. Testicular cancer has a 95% survival rate when only a few decades ago it was 5%. Many pediatric leukemias we can treat with some efficacy. For cancers we can't cure, we can certainly make the remaining life better. In oncology, is it isn't about who you lose - its about who you don't. Those are the cases where, after, you can look Mother Nature in the eyes and say "we beat you."
The other thing about oncology, although this applies to other fields as well (for example, transplant surgery, which I am on right now), is the effect it has on me as a person. Its so easy to go home at night and be tired and think, "I want to do nothing", or "I am too tired to go on a run." Then you remember the stage IV cancer patient who is bed-ridden and beyond cure, without long to live. Or you might remember the young guy who is stuck in the ICU. He already had a liver transplant once to save his life, but his immune system has systematically destroyed it despite our best efforts. Each day we see the new numbers, each day more abnormal, as the liver functions less and less.
Remember those things and all of the sudden, you have the energy to go for a run or to go out and socialize - because you can. Because you are so aware that someday, you won't be able to. Think forward - many of us will be in that very position some day. What would we give for the chance to come back and be 28 and be healthy enough to do those things? If that time comes for me, I will smile when it does, because I will know I did. With the right perspective, oncology is an incredibly uplifting discipline.
Wednesday, June 29, 2011
Reason as a weapon
A recent NYT article about reason summarized viewers responses as thus:
"Reason Seen More as Weapon than Path to Truth".
The NYT went on to describe the title: "a description, that implied that reason is not, as we generally think, directed to attaining truth, but rather to winning arguments."
I recently heard a quote by some physician which has become one of my all-time favorites. Roughly, it is: "Humans are forced to choose between truth and certainty. We can have one, or the other, but we cannot have both."
A person who would prefer certainty over truth would definitely perceive reason to be a weapon. If such a person were interested in 'truth' in the first place, then 'certainty' would not have been their priority all along. To be interested in truth is to be interested in reason. To be interested in certainty is to be indifferent at best, or hostile at worst, to reason.
This is why so many religious people are hostile to science these days (actually the cause is more a product of manipulative religious leaders creating a false enemy to inflate their own sense of importance, but I digress). When people are told that the theory of evolution undermines their religious beliefs (it shouldn't), they are instinctively hostile to the logic and reason of the theory. To let any of it in would be to suspend their certainty about how the world was created.
Another interesting thing about this quote (that we can have truth or certainty but not both) is that it is reflected in the physical world by the Heisenberg Uncertainty Principle. The principle states that we may know the position of a subatomic particle, or we may know the momentum of the particle, but we can never know both.
As for me, I always choose truth over certainty. I am 100% certain of that. Or am I?
"Reason Seen More as Weapon than Path to Truth".
The NYT went on to describe the title: "a description, that implied that reason is not, as we generally think, directed to attaining truth, but rather to winning arguments."
I recently heard a quote by some physician which has become one of my all-time favorites. Roughly, it is: "Humans are forced to choose between truth and certainty. We can have one, or the other, but we cannot have both."
A person who would prefer certainty over truth would definitely perceive reason to be a weapon. If such a person were interested in 'truth' in the first place, then 'certainty' would not have been their priority all along. To be interested in truth is to be interested in reason. To be interested in certainty is to be indifferent at best, or hostile at worst, to reason.
This is why so many religious people are hostile to science these days (actually the cause is more a product of manipulative religious leaders creating a false enemy to inflate their own sense of importance, but I digress). When people are told that the theory of evolution undermines their religious beliefs (it shouldn't), they are instinctively hostile to the logic and reason of the theory. To let any of it in would be to suspend their certainty about how the world was created.
Another interesting thing about this quote (that we can have truth or certainty but not both) is that it is reflected in the physical world by the Heisenberg Uncertainty Principle. The principle states that we may know the position of a subatomic particle, or we may know the momentum of the particle, but we can never know both.
As for me, I always choose truth over certainty. I am 100% certain of that. Or am I?
Tuesday, May 17, 2011
Impressions from East Africa: historical development, communities, and finances
Imagine Tanzania in the year 1900. This is a land that is 50% larger than the state of Texas, supporting a population of maybe 3 million. There was no infrastructure, no centralized government, and really, no history of a centralized government. Contrast that to Qing China, the Manchurian dynasty which ruled China up to modern times. Qing China in 1900 was arguably still one of the great powers of the world even if it was quickly falling apart. Back then, the population of China was several hundreds of millions. There was a history of civilization going back four millennia and certainly a tradition of strong centralized government, despite the fact that China is so geographically large.
One of the things required to create a modern nation state and the appropriate institutions is a sufficient population density in the surrounding area. China apparently hit that necessary population density thousands of years ago, but we should remember that Tanzania was nowhere near that threshold even one hundred years ago. A great book that expounds on this topic is "Guns, Germs, and Steel" for anyone interested. Despite these great contrasts, GDP per person in China and Tanzania 30 years ago was not so different. The take-home point is this: strong economic and political development doesn't just happen by default. It can get hindered by any number of things.
Think back to Tanzania in 1900: sparsely populated, inaccessible, every community for themselves. These communities, like other small communities throughout history, would need to be close knit. Vertical ties may involve patronage from a chief or leader who has surplus resources. That leader can distribute those resources to neighbors and subordinates in order to strengthen ties and bonds between them. Horizontal ties would involve relationships between friends, relatives, and neighbors who are on equal footing. In a small self-sufficient society, it is all about hedging risk. Sometimes one family has a good hunt, or a good harvest. Another family may fail to find an animal, or will have crops which get killed by fungus. Obviously, if neighbors are willing to readily share everything they have, the risk gets hedged throughout the community as a whole and everyone is better off.
In a century, the population of Tanzania has increased by 10-fold or more. It has been thrown into the modern world, and expected to develop sound Western institutions of government. Are these aforementioned cultural survival traits just going to disappear in a single human lifetime? Vertical ties of patronage in 1900 are manifested in the modern world as endemic corruption. Horizontal ties between neighbors manifest as a lack of savings. Let me expound on this last point. When we were in Kenya, one Westerner was telling me that if any person makes money or has a big payday, they immediately go out and spend it on all of their friends at the bar or restaurant. An employee of this person didn't want to keep her money at her house. She was afraid a friend or family would ask for it, and she would be obligated to give it away. These two examples help illustrate a source of serious economic problems. Without savings, there can be no investment. Without investment, there is no productivity growth.
I do appreciate that this dynamic is a testament to the strength of the community in Tanzania and Kenya, which is a wonderful thing. I've figured out that it is a big part of the attraction that Colleen feels to east Africa. Really, it is the same for me. The palpable sense of community is something we just don't have in the West anymore for the most part, and its something one can never perceive from photos of Africa. One has to be there to feel that pulse. Not to denigrate my own culture, because I love the West and I think it is the pinnacle of human existence: but this resource-sharing dynamic in east Africa is more instinctively "normal", in the sense that humans are hard-wired to operate that way. Sharing of resources in small, close-knit communities has been the norm throughout human history.
The communal spirit is what enabled clans and small groups of people to survive, because everyone is hedging their successes and failures on their close relatives. Only with the advent of larger towns and cities using national currencies have people in the West in particular moved away from this. There is still an intense attraction to what they have in east Africa, because I believe our brains were designed to function in small communities like they have (and we used to have) instead of the relatively lonely and unfriendly places in which we live in the West. In fact I've read psychological studies which suggest that 150 people is the ideal community size for Homo sapiens; we can keep tabs on and socially interact with that many people.
The move from small self-sufficient community groups to larger cities and towns in the West occurred over an extended period of hundreds of years. This gradual transition allowed for the culture to adjust slowly. We were able to develop a norm of anti-corruption (even though it still happens everywhere). Since everyone was participating in government we began to think in terms of nation or kingdom instead of tribe or clan. Notice in places where political participation was forbidden by some group or another (Jews in Europe, African Americans in the USA) there remained into modern times sort of "tribal" (us versus them) schisms that we see in the news all the time in east Africa and are oh so shocked by. Tribal tendencies, xenophobia, racism - we are talking about the same thing. Barack Obama, show us your birth certificate!
Anyway. If I had one point to this post, I guess it would be this: many people look at the lack of economic development in Africa and think "what has gone wrong?" My reaction is completely different: How could they be anywhere else? There has been so much change in such a short amount of time in east Africa, there is just no way it could have happened smoothly. In east Africa we've been expecting them to make the sort of adjustments in 100 years that in the West we made over the last 700 and in China they made over the last 4,000. This isn't even adding in the complicated history of colonialism, the effect instability of neighbors has on local development, and the effect of poor government economic policies. I don't even need to think about colonialism to not be surprised by the current political and economic position in east Africa. Yet only 30 years ago China was every bit as poor as Tanzania. 70 years ago Italy still had endemic malaria, a high birth rate, and extremely high infant mortality. I don't know how the current situation could make anyone pessimistic about the future of Africa, because to me it makes perfect sense that Africans are where they are now given from where they have come.
Its all about where they are going, and I think the future is promising. Maybe I'm too optimistic, but its never smart to bet against humanity. Topic for another post.
One of the things required to create a modern nation state and the appropriate institutions is a sufficient population density in the surrounding area. China apparently hit that necessary population density thousands of years ago, but we should remember that Tanzania was nowhere near that threshold even one hundred years ago. A great book that expounds on this topic is "Guns, Germs, and Steel" for anyone interested. Despite these great contrasts, GDP per person in China and Tanzania 30 years ago was not so different. The take-home point is this: strong economic and political development doesn't just happen by default. It can get hindered by any number of things.
Think back to Tanzania in 1900: sparsely populated, inaccessible, every community for themselves. These communities, like other small communities throughout history, would need to be close knit. Vertical ties may involve patronage from a chief or leader who has surplus resources. That leader can distribute those resources to neighbors and subordinates in order to strengthen ties and bonds between them. Horizontal ties would involve relationships between friends, relatives, and neighbors who are on equal footing. In a small self-sufficient society, it is all about hedging risk. Sometimes one family has a good hunt, or a good harvest. Another family may fail to find an animal, or will have crops which get killed by fungus. Obviously, if neighbors are willing to readily share everything they have, the risk gets hedged throughout the community as a whole and everyone is better off.
In a century, the population of Tanzania has increased by 10-fold or more. It has been thrown into the modern world, and expected to develop sound Western institutions of government. Are these aforementioned cultural survival traits just going to disappear in a single human lifetime? Vertical ties of patronage in 1900 are manifested in the modern world as endemic corruption. Horizontal ties between neighbors manifest as a lack of savings. Let me expound on this last point. When we were in Kenya, one Westerner was telling me that if any person makes money or has a big payday, they immediately go out and spend it on all of their friends at the bar or restaurant. An employee of this person didn't want to keep her money at her house. She was afraid a friend or family would ask for it, and she would be obligated to give it away. These two examples help illustrate a source of serious economic problems. Without savings, there can be no investment. Without investment, there is no productivity growth.
I do appreciate that this dynamic is a testament to the strength of the community in Tanzania and Kenya, which is a wonderful thing. I've figured out that it is a big part of the attraction that Colleen feels to east Africa. Really, it is the same for me. The palpable sense of community is something we just don't have in the West anymore for the most part, and its something one can never perceive from photos of Africa. One has to be there to feel that pulse. Not to denigrate my own culture, because I love the West and I think it is the pinnacle of human existence: but this resource-sharing dynamic in east Africa is more instinctively "normal", in the sense that humans are hard-wired to operate that way. Sharing of resources in small, close-knit communities has been the norm throughout human history.
The communal spirit is what enabled clans and small groups of people to survive, because everyone is hedging their successes and failures on their close relatives. Only with the advent of larger towns and cities using national currencies have people in the West in particular moved away from this. There is still an intense attraction to what they have in east Africa, because I believe our brains were designed to function in small communities like they have (and we used to have) instead of the relatively lonely and unfriendly places in which we live in the West. In fact I've read psychological studies which suggest that 150 people is the ideal community size for Homo sapiens; we can keep tabs on and socially interact with that many people.
The move from small self-sufficient community groups to larger cities and towns in the West occurred over an extended period of hundreds of years. This gradual transition allowed for the culture to adjust slowly. We were able to develop a norm of anti-corruption (even though it still happens everywhere). Since everyone was participating in government we began to think in terms of nation or kingdom instead of tribe or clan. Notice in places where political participation was forbidden by some group or another (Jews in Europe, African Americans in the USA) there remained into modern times sort of "tribal" (us versus them) schisms that we see in the news all the time in east Africa and are oh so shocked by. Tribal tendencies, xenophobia, racism - we are talking about the same thing. Barack Obama, show us your birth certificate!
Anyway. If I had one point to this post, I guess it would be this: many people look at the lack of economic development in Africa and think "what has gone wrong?" My reaction is completely different: How could they be anywhere else? There has been so much change in such a short amount of time in east Africa, there is just no way it could have happened smoothly. In east Africa we've been expecting them to make the sort of adjustments in 100 years that in the West we made over the last 700 and in China they made over the last 4,000. This isn't even adding in the complicated history of colonialism, the effect instability of neighbors has on local development, and the effect of poor government economic policies. I don't even need to think about colonialism to not be surprised by the current political and economic position in east Africa. Yet only 30 years ago China was every bit as poor as Tanzania. 70 years ago Italy still had endemic malaria, a high birth rate, and extremely high infant mortality. I don't know how the current situation could make anyone pessimistic about the future of Africa, because to me it makes perfect sense that Africans are where they are now given from where they have come.
Its all about where they are going, and I think the future is promising. Maybe I'm too optimistic, but its never smart to bet against humanity. Topic for another post.
Saturday, October 02, 2010
Heinrich Heine in 1834
Yes, 1834.
Do not smile at my advice -- the advice of a dreamer who warns you against Kantians, Fichteans, and philosophers of nature. Do not smile at the visionary who anticipates the same revolution in the realm of the visible as has taken place in the spiritual. Thought precedes action as lightning precedes thunder. German thunder is of true Germanic character; it is not very nimble, but rumbles along ponderously. Yet, it will come and when you hear a crashing such as never before has been heard in the world's history, then you know that the German thunderbolt has fallen at last. At that uproar the eagles of the air will drop dead, and lions in the remotest deserts of Africa will hide in their royal dens. A play will be performed in Germany which will make the French Revolution look like an innocent idyll."
"Christianity - and that is its greatest merit - has somewhat mitigated that brutal Germanic love of war, but it could not destroy it. Should that subduing talisman, the cross, be shattered, the frenzied madness of the ancient warriors, that insane Berserk rage of which Nordic bards have spoken and sung so often, will once more burst into flame. This talisman is fragile, and the day will come when it will collapse miserably. Then the ancient stony gods will rise from the forgotten debris and rub the dust of a thousand years from their eyes, and finally Thor with his giant hammer will jump up and smash the Gothic cathedrals.
Do not smile at my advice -- the advice of a dreamer who warns you against Kantians, Fichteans, and philosophers of nature. Do not smile at the visionary who anticipates the same revolution in the realm of the visible as has taken place in the spiritual. Thought precedes action as lightning precedes thunder. German thunder is of true Germanic character; it is not very nimble, but rumbles along ponderously. Yet, it will come and when you hear a crashing such as never before has been heard in the world's history, then you know that the German thunderbolt has fallen at last. At that uproar the eagles of the air will drop dead, and lions in the remotest deserts of Africa will hide in their royal dens. A play will be performed in Germany which will make the French Revolution look like an innocent idyll."
Tuesday, April 20, 2010
The Bible and the Constitution
The Gospel According to Matthew: "And when you pray, do not be like
the hypocrites, for they love to pray standing in the synagogues and
on the street corners to be seen by men. I tell you the truth, they
have received their reward in full. But when you pray, go into your
room, close the door and pray to your Father, who is unseen. Then your
Father, who sees what is done in secret, will reward you."
the hypocrites, for they love to pray standing in the synagogues and
on the street corners to be seen by men. I tell you the truth, they
have received their reward in full. But when you pray, go into your
room, close the door and pray to your Father, who is unseen. Then your
Father, who sees what is done in secret, will reward you."
The Constitution of the United States of America: "Congress shall
make no law respecting the establishment of religion, or prohibiting
the free exercise thereof."
I'm not sure if she was directly heeding the words of Jesus Christ, or
simply interpreting the constitution with respect to the intentions of
the Founding Fathers. Either way, District Court Judge Barbara B.
Crabb has just ruled that the National Day of Prayer Proclamation,
instituted by Ronald Reagan in 1988, is unconstitutional. In doing
so, she has thrown out a law that was both an affront to the Bible and
the intentions of Jesus Christ, and an affront to the Constitution.
No doubt, Jesus Christ and the Founding Fathers would be proud of
Judge Crabb's ruling.
No doubt, Fox News and the rest of the people who systematically
exploit the Christian religion as a political tool will feign outrage.
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